Provider Demographics
NPI:1376744433
Name:PETERSEN, DARLENE L (MD)
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:L
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:5640 S 3500 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9158
Practice Address - Country:US
Practice Address - Phone:801-773-2838
Practice Address - Fax:801-773-3025
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2023-11-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT292621-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine